www.courts.ca.gov Clerk stamps date here when form is filed.Fill in court name and street address: Court fills in case number when form is filed. Fill in child's name and date of birth:have to (first)(middle)(last) (years)(months)(days) (years)(months)(days) Describe here: Describe here: (first)(middle)(last) (explain): American LegalNet, Inc. www.FormsWorkFlow.com (list here): Describe here: Describe here: Describe how well the child sleeps and about how many hours each day: (list any other treatment here): American LegalNet, Inc. www.FormsWorkFlow.com If the child is not taking this/any psychotropic medicine now, skip to question 24. If Yes, describe here: If Yes, describe here: If No, describe here: If Yes, describe here: If Yes, describe here: American LegalNet, Inc. www.FormsWorkFlow.com If No, describe what it222s like: If Yes, explain who and how often: If Yes, check one: How many pounds? (list any other side effects here): Sign your name Type or print your name American LegalNet, Inc. www.FormsWorkFlow.com